It’s more complicated than that….


Monday 18th April 2016 marks to the start of a campaign on the part of families who have a member of their family in an Assessment and Treatment Unit (ATU) – see for the standards that define an ATU.

3,000 people.  Members of 3,000 families who love them.

As commissioners and social workers, in our local authority next week we will be asking ourselves the question – who do we know about in an ATU who we have responsibility for and what are we doing to get them home?

That we have to start by asking the question – who do we know about in ATUs – matters in a way that will no doubt frustrate those of you who are taking time to read this blog.  You would reasonably expect, rightly so given Care Act responsibilities, that we should automatically know who is an ATU.  However, given the routes into ATUs, as local authority commissioners we don’t necessarily do so, which leads to the near invisibility of people who are detained in in-patient settings – see and

There are several reasons for this, which are not given as an excuse, but hopefully will help shed some light on some of the issues faced by social workers and local authority commissioners which other, clever people than us, can help us with.

Firstly, the lead commissioners for placements in ATU’s aren’t from Local Authorities.  Inpatient admissions for adults with a learning disability are commissioned by health services (NHS England and/or the CCG).  CCG commissioning leads responsible for inpatient admissions, are also usually the people who lead on commissioning of Continuing Health Care funded community support.  Sometimes the Ministry of Justice are also involved.

Inpatient Commissioners

Health commissioners do not as a matter of course share details with Local Authority commissioners about who they have placed where.  There are lots of explanations for this – but I suspect the most important one is that on a day to day basis CHC is the fault line which divides health and social care.  CHC is the single biggest barrier to integrating a seamless, personalised support model around the person which puts them in full control of their support.  CHC is controlled to the nth degree – see the really quite odd policy position of CCGs “creating a local Personal Health Budget offer” for how you can choose to spend your PHB- – either you are in control or you aren’t – an “offer” defined and limited by commissioners is not personalisation as self-advocacy groups define it.   The conflict on the front line generated by very different, deeply held assumptions between health and social care about who should be in control of defining what support is offered to get someone home, and crucially who has to pay for it, isn’t conducive to building the sort of trusting relationships required to foster cultures of collaboration.

Secondly, CCG commissioners don’t talk about ATU’s – they talk about “tiers” of health services to “manage” inpatient admissions.  4 tiers.

4 tiers

And at the top of the 4th tier, there are 6 catagories….  Confused yet…?  Still with me…?  See the Royal College of Psychiatrist’s explanation of why ATU isn’t a good description for forensic inpatient services as it is ‘more complicated than that’ –

category 1: high, medium and low secure forensic beds

category 2: acute admission beds within specialised learning disability units

category 3: acute admission beds within generic mental health settings

category 4: forensic rehabilitation beds

category 5: complex continuing care and rehabilitation beds

category 6: other beds including those for specialist neuropsychiatric conditions

As a local authority social worker or commissioner the focus of any discussion with a CCG CHC Lead who is tasked with arranging for a discharge from an ATU is about how commissioners arrange for people to ‘step down the tiers’.  This is code for how people move through the funding system from the NHS to social care paying for the person’s support.  This is particularly important given the Transforming Care agenda – to qualify for what NHS England have oddly chosen to call ‘dowry’ funding (I find the use of the word dowry to be a very odd one indeed in the context of getting people home from hospital), people need to have been resident in an ATU for over 5 years.

4.44 dowries

According to Chris Hatton’s figures – only 17% of people currently in ATUs would qualify for these funds.  Clarity over how the support home is going to paid for the other 83% of people is a hugely important issue if we are to be able to make it happen for the 3,000 people who just want to go home.  If I was a policy maker, I would do something very simple – I would mandate CCG spend on learning disabilities into the Better Care Fund (the finance data was collected last summer by NHS England so they know what they need to do to make this happen….)

So, what could you do as a social worker or local authority commissioner during the week:

  • Read and make space to reflect on the 7 Days of Action blog 
  • Find out how many people in your Local Authority are placed in ATUs
  • Of these, find out how many meet the definition for support to get home under the national Transforming Care programme
  • Ask who the allocated social worker and commissioner are who is working to get the person home
  • Speak to those workers and ask them, what specific plan is in place to get the person home and what can you do to help them make this happen
  • As a team, ask the CCG commissioners to confirm exactly how many people are the CCG are aware of within ATUs – and to confirm this number with NHS England who need to confirm it with the Ministry of Justice
  • Don’t be confused by the noise – it is only complicated if you chose to let it be

Find out more

2 replies on “It’s more complicated than that….”

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